President’s Message

President’s Message

By Andrea Chronis-Tuscano, PhD

First I would like to say Happy Summer, Friends! We made it! For those of you in university or school settings, summer is a time when things slow down and we can take a bit of time to nourish ourselves. If you’re anything like me, your first inclination is to make a to-do list that is far too long. This summer, I encourage you to prioritize you and your well being. Make fun plans, rest, spend time with loved ones, praise yourself for what you do get done, and practice acceptance for what you do not. One of my favorite mantras is “if you don’t listen to your body when it whispers, it will scream at you!” So, friends, I encourage you to commit to taking care of YOU this summer.

In this issue, I want to tell you about some new findings featured in the upcoming issue of our division journal, the Journal of Clinical Child and Adolescent Psychology (JCCAP). My colleague, Dr. Nadia Bounoua, and I wrote a commentary on Dr. Melissa Danielson and colleagues’ latest report on the National Survey on Children’s Health (NSCH), a population-based study surveying over 45,000 families across the U.S.

According to the NSCH, in 2022, the prevalence of ADHD rose to 11%, up from 9.8% in 2016-2019 (and only 6-8% in 2000). This increased prevalence rate could be due, in part, to stressors unique to the pandemic, increased awareness around ADHD or children’s mental health more generally, and/or increased utilization of telehealth as a mode of mental health service delivery. In a population survey like this, of course, we cannot be sure if diagnoses were accurate or based on evidence-based assessments. Parents were simply asked “whether a doctor or other health care provider ever told them that their child had attention deficit disorder (ADD) or ADHD.” We will have to wait to see if this increased prevalence rate will persist, continue to grow, or return to pre-pandemic levels.

However, what I want to focus on here is the second part of the report: There were huge disparities in who received an ADHD diagnosis and evidence-based treatments (e.g., medication, behavior therapy), and who did not. First and unsurprisingly, more boys than girls were diagnosed with ADHD. ADHD in girls and women often goes undiagnosed or misdiagnosed, largely due to misperceptions about ADHD. This can have devastating effects on the self-esteem of girls and women with ADHD and can ultimately contribute to devastating outcomes, like suicidal thoughts and behaviors. Of course, the literature on ADHD (including the DSM diagnostic criteria), until relatively recently, was largely based on male samples, as were our treatment studies. We still have a long way to go, but fortunately several efforts to increase awareness are underway.

The 2022 NSCH also showed lower prevalence rates of ADHD among Latinx and Asian American youth. Although it is possible that these groups are truly less likely to have ADHD, a variety of factors might contribute to underdiagnosis, including: Low mental health literacy, mental health stigma, structural/ practical barriers (e.g., lack of culturally competent providers, lack of information or services offered in other languages aside from English, insurance coverage), and lack of parental support and communication about help-seeking. Fortunately, the disparity in rates of diagnosis and help seeking for girls, Asian American, and Latinx youth are shrinking compared to prior NSCH reports.

In contrast, children from families with socioeconomic disadvantage – lower income, those with lower levels of parental education, and those receiving public insurance – were more likely to get diagnosed with ADHD. Youth with socioeconomic disadvantage were also more severely affected. Despite strong evidence that ADHD has a neurobiological and genetic etiology, broader contextual factors such as school, neighborhood, culture, and poverty influence the developmental course of ADHD and access to care.

With regard to EBT receipt, only 54% of youth with ADHD were receiving medication and 44% were receiving behavioral interventions. Consistent with prior reports and well-documented ADHD medication hesitation among Latinx parents, Hispanic and non-English speaking youth were less likely to take medications. Youth in the southern portion of the U.S. were more likely to get medication only. On the other hand, younger children were more likely to receive behavior therapy only–in line with AAP recommendations.

Despite the literature demonstrating significant advantage of combined treatments over unimodal treatments on functional outcomes, as well as American Academy of Pediatrics (AAP) and American Academy of Child and Adolescent Psychiatry (AACAP) practice parameters encouraging combined treatment, only about one-quarter of youth with ADHD received both stimulant medication and behavior therapy.

Perhaps the most unfortunate finding is that 30% of children with ADHD received no treatment at all–a rate which is even higher than past NSCH reports! Adolescents were less likely to get either treatment than the other age groups, despite increased academic demands, risk for depression/suicide and substance abuse in this age group. Youth living in non-English speaking households were also less likely to get any treatment for their ADHD. Non-English-speaking parents may be less aware of ADHD treatment options, as resources may not be available in their language. They may also feel less comfortable advocating or asking for services (such as school accommodations) because of language barriers or lower levels of educational attainment. These families may also be experiencing mental health stigma, medical mistrust and other access barriers (e.g., insurance, transportation, unemployment). A major research and policy agenda is, therefore, to examine how we can improve psychoeducation, openness to treatment, as well as access to evidence-based ADHD treatment among non-English speaking families.

These findings are obviously sobering. We have come a long way in identifying several evidence-based treatments for ADHD in our research, and yet, so many youth in the U.S. are not accessing them. What can we do to address this? Nadia and I put forth a number of ideas in our commentary. First and foremost, and in line with the SCCAP theme for our 2024 American Psychological Association Conference, we need to stop and listen. We need to collect qualitative data to better understand how a diagnosis of ADHD is perceived across cultures; how parents and youth view our existing treatments (both positive and negative); how we can frame treatments in line with cultural values (e.g., academic success); where families from different cultures naturally turn when they have concerns about their children; and what barriers families face when they try to get help for their children. These discussions could inform the way we talk with youth and families about ADHD, the most effective ways to provide psychoeducation, how we can engage in shared decision making around what to do next in terms of treatment options and goals, and how we can  reduce some of the barriers to help seeking. Delivering EBTs in schools and pediatric primary care can reduce at least some of these access barriers. It can also be fruitful to engage community members in spreading the word about EBTs and assisting with the delivery of EBTs. Families may be more open to hearing these messages from trusted sources who share lived experiences. Finally, much can be done to diversify our clinical child and adolescent psychology workforce. Together, we, alongside policymakers, can work to reduce disparities in the diagnosis and treatment of ADHD!

References

Danielson, M. L., Claussen, A. H., Bitski, R. H., Katz S. M., Newsome, K., Blumberg, S. J., Kogan. M. D., & Ghandour, R. (in press). ADHD Prevalence Among U.S. Children and Adolescents in 2022: Diagnosis, Severity, Co-Occurring Disorders, and Treatment. Journal of Clinical Child and Adolescent Psychology. https://doi.org/10.1080/15374416.2024.2335625

Chronis-Tuscano, A. & Bounoua, N. (in press). ADHD Prevalence Rose, Yet Disparities Remain: Commentary on the 2022 National Survey of Children’s Health. Journal of Clinical Child and Adolescent Psychology. https://doi.org/10.1080/15374416.2024.2359075